Provider Demographics
NPI:1609854108
Name:GOLWALA, PRAVIN NANALAL
Entity Type:Individual
Prefix:
First Name:PRAVIN
Middle Name:NANALAL
Last Name:GOLWALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2106 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457
Mailing Address - Country:US
Mailing Address - Phone:718-584-9396
Mailing Address - Fax:
Practice Address - Street 1:2106 GRAND CONCOURSE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2800
Practice Address - Country:US
Practice Address - Phone:718-584-9396
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0397021223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice